The November 25, 2015 “Case Connections” looks at four JBJS Case Connector cases involving injuries to the cervical spine in which the outcomes were about as good as anyone could have wished, considering the potential for disaster. Two of the cases required surgical intervention to achieve the positive outcomes, but the outcomes in the other two cases were remarkably positive without surgery.
While these four cases of cervical spine injury had relatively “happy endings,” orthopaedic surgeons and other health-care professionals treating patients with any suspected spine injury are trained to proceed with the utmost care and caution out of concern for devastating neurological sequelae. Watchful waiting under close medical scrutiny is sometimes warranted, but many cases of cervical fracture, dislocation, or instability call for operative stabilization to reduce the risk of life-changing or life-threatening consequences. The potential seriousness of surgical complications when operating on the spine must also be recognized.
The contributions to the field of shoulder surgery from Dr. Charles Neer are too numerous to document in any one commentary. A partial list would include shoulder arthroplasty (both hemi and total), the concept of impingement and acromial pathology, multidirectional instability, and the role of the AC joint in rotator cuff pathology.
Dr. Neer also made numerous contributions to the understanding of fracture care, including the distal femur and clavicle. But no area of fracture management was of greater interest to him and his colleagues at Columbia than the proximal humerus. This classic manuscript has been cited thousands of time and remains the seminal piece in the foundation of understanding fracture patterns in the proximal humerus—and the attendant treatment implications.
Dr. Neer introduced the concept of the four parts of the proximal humerus in this manuscript, and with it the implication of isolating the humeral-head blood supply in a four-part fracture. The impetus to understand the complication of avascular necrosis of the humeral head began with this manuscript, as did the critical debates regarding surgical versus nonsurgical intervention and replace-or-fix. An important area of ongoing debate is Neer’s definition of a “displaced” fracture in the proximal humerus as having > 1 cm of displacement. The orthopaedic community to this day is wrestling with this definition and its relevance to treatment and outcomes.
This classic manuscript also helped launch a decades-old conversation about the role of fracture or musculoskeletal-disease classification systems. Subsequent publications by Zuckerman and Gerber identified issues with inter- and intra-rater reliability when applying the Neer classification system to a set of radiographs. The reliability debate surrounding this classification system led us to understand the issue of forcing continuous variables (fracture lines are infinite in their trajectory and displacement) into dichotomous variables (a classification system). Because of Dr. Neer’s work and subsequent research, our community understands that when we make these classification designations, we will agree about 60% of the time (kappa statistic of 0.6). That level of agreement is not reflective of a “good” or “bad” classification system; rather, it’s a consequence of moving a continuous variable to a dichotomous variable.
So we remain indebted to Dr. Neer not only for laying the foundation for the treatment of patients with proximal humeral fractures, but also for vastly expanding our knowledge regarding the role, strengths, and weaknesses of disease and fracture-classification systems.
Marc Swiontkowski, MD
In two separate studies published recently in the BMJ, New Zealand researchers concluded that increased calcium intake, through diet or supplements, is unlikely to have clinically meaningful effects on bone density or fracture prevention. The findings call into question recommendations from most health care professionals for daily calcium intake of at least 1,000 to 1,200 mg in older adults.
The first study reviewed 59 randomized controlled trials (nearly 14,000 patients total) that examined the association between bone mineral density (BMD) and either dietary or supplemental sources of calcium. Increases in BMD ranged from only 0.6% to 1.8% with increased calcium intake, regardless of the source and whether calcium was taken with vitamin D. The authors concluded that these small BMD effects were “unlikely to translate into clinically meaningful reductions in fractures.”
The second study reviewed 28 randomized trials and 44 observational studies (more than 58.000 patients total) that examined the relationship between increased calcium intake and fracture prevention among people older than 50 years. The analysis found that calcium supplements have “small inconsistent benefits on fracture prevention” but that overall “there is currently no evidence that increasing calcium intake prevents fractures.”
What do you make of these findings? Please comment by clicking on the “Leave a comment” button in the box next to the title.
“Health-related quality of life” is easier to say than to measure. In the September 2, 2015 edition of The Journal, Schottel et al. document the impact of a diaphyseal nonunion on health-related quality of life using the well-accepted methodology of time trade-off. In this approach, patients are asked what percentage of their remaining life they would be willing to trade for perfect health, free from the disability in question.
Among the 832 long-bone nonunions studied, Schottel et al. found patients were willing to trade an average of 32% of their remaining lifespan for perfect health. Patients with nonunions of the forearm were willing to trade the greatest percentage of their lives (46%) to be rid of their disability.
This study demonstrates negative impacts of long bone nonunions that are greater than the patient-perceived impacts of diabetes, stroke, or AIDS, with all their attendant comorbidities and medical management issues. These findings serve to re-emphasize how important musculoskeletal function is for optimum quality of life—a fact that all practitioners who treat patients with musculoskeletal issues realize.
I’m certain more than a few of these patients developed a nonunion partly due to poor surgical indications and technique. Hence, our emphasis needs to be on curtailing long bone nonunions through injury-prevention strategies and optimum diagnosis and treatment of diaphyseal fractures. Also, as Mundi and Bhandari point out in their commentary to the Schottel et al. study, “It would behoove orthopaedic care providers to identify early patients with risk factors for nonunion, such that close surveillance and timely intervention can be initiated to minimize nonunion risk.”
Our orthopaedic community should be out in front of this issue with honest evaluations of surgical indications and outcomes so that we can all improve our judgment and surgical skill. While injury mechanisms and severity and patient characteristics undoubtedly also play a major role in the development of long bone nonunions, we orthopaedists should minimize as much as possible our part in creating these high-impact health problems.
Marc Swiontkowski, MD
Researchers at Vanderbilt University Medical Center have concluded that fibrin, a protein involved in blood clotting and found abundantly around the site of new bone fractures, impedes rather than supports fracture healing.
Their recent study in The Journal of Clinical Investigation looked at mice that had experimentally induced deficits in either fibrin production or fibrin clearance. Researchers found normal fracture repair in mice without fibrin and impaired vascularization and fracture healing in mice with inhibited fibrin clearance. They also saw increased heterotopic ossification in the mice unable to remove fibrin.
In a Vanderbilt press release, study coauthor Jonathan Schoenecker, MD, commented that “any condition associated with vascular disease and thrombosis will impair fracture healing.” These findings, he suggested, may explain why obesity, diabetes, smoking, and old age—all of which are associated with impaired fibrin clearance—are also associated with impaired fracture healing. Dr. Schoenecker went on to speculate that anti-clotting drugs commonly used to treat cardiovascular conditions may find new applications in enhancing fracture repair.
The prescribing of selective serotonin reuptake inhibitors (SSRIs) for nonpsychiatric disorders has climbed steadily in recent years, and the June 2013 FDA approval of paroxetine to treat hot flashes associated with menopause is likely to expose more women to this popular class of antidepressants.
A new observational, claims-based analysis found that 137,000 women between the ages of 40 and 64 without mental illness who started an SSRI between 1998 and 2010 were 67% to 76% more likely to break a bone during the subsequent one to five years than 236,000 women of the same age who took indigestion drugs during the same time period. The analysis allowed for a six-month lag time to account for a presumed delay in the clinical effects of SSRIs on bone density. All told, the findings suggest that “shorter duration of treatment might mitigate the risk of developing excess fractures,” co-author Yi-han Sheu told MedPage Today.
Noting that the study did not account for varying dosages of SSRIs, Holly Puritz, MD, a spokesperson for the American College of Obstetricians and Gynecologists, told MedPage Today, “Overall fracture rates are extremely low in this age group, so noting an increase can look significant when discussed as a percentage, but [is] less meaningful when actual numbers are looked at.” And then there’s this possibly confounding factor: A study reported on in OrthoBuzz earlier this year found that hot flashes in and of themselves were associated with an increased risk of hip fractures in women.
Most surgeons believe that an open fracture of an extremity is an indication for antibiotic prophylaxis. However, few are familiar with the evidence to support this practice, and the optimum duration of treatment is unknown. In the June 2015 issue of JBJS Reviews, Chang et al. report the results of a systematic review of randomized controlled trials to help shed light on this question. The investigators performed a review of different antibiotic regimens, including antibiotic prophylaxis versus no prophylaxis, longer versus shorter durations of treatment, and the use of alternative drugs.
Using systematic review and meta-analysis methodology, the investigators identified 329 potentially eligible articles, of which seventeen were found to be eligible for inclusion in the analysis. Four randomized controlled trials that involved 472 patients demonstrated significantly lower rates of infection in patients who received antibiotic prophylaxis compared with those who did not receive antibiotic prophylaxis. Three studies involving 1104 patients demonstrated no difference in the infection rate when a longer duration of antibiotic prophylaxis was compared with a shorter duration (three to five days versus one day).
However, confidence in the estimates for both of these questions was low to moderate, and individual comparisons of alternate drugs yielded only low to very low confidence. The investigators concluded that the results of randomized controlled trials performed to date provide evidence that antibiotic prophylaxis reduces infection and that treatment for as short as one day is as effective as treatment for three to five days. Although the evidence warrants only low to moderate confidence, these findings provide support for the design and execution of a large, multicenter, randomized controlled trial to address the question of how antibiotics may be best used in the treatment of open extremity fractures.
Thomas A. Einhorn, MD
Editor, JBJS Reviews
Golf enthusiasts endlessly debate club design and selection when approaching standard situations on the course. For example, for a shot to a large green from 100 yards, one golfer might choose a pitching wedge, while another would opt for a sand wedge or even a chocked-down nine iron. There are no style points in golf for this shot—what matters is getting the ball close to the pin.
There is a strong similarity between this club-selection dilemma and fixation of midshaft clavicle fractures. Two well-done Level I randomized controlled trials in the April 15, 2015 edition of The Journal (van der Meijden et al. and Andrade-Silva et al.) support the notion that, when a patient’s fracture displacement and clinical characteristics warrant fixation, it does not matter whether the surgeon chooses an intramedullary pin or a plate. This decision must be made based on the surgeon’s experience, skill, prior outcomes, and a candid discussion of the options with the patient.
One area of particular concern is the highly comminuted midshaft fracture that is not length-stable. The Andrade-Silva et al. trial showed that, in this setting, the reconstruction plate may well result in clavicular shortening that is statistically greater than shortening with the intramedullary device, but was not found to be clinically important. Still, in those cases a more rigid plate construct may be preferable.
Otherwise, pin or plate achieves equivalent clinical outcomes, just as the sand wedge and pitching wedge can both get the ball close to the pin. It is the experience and skill of the person with the club in hand that matters.
Click here for a commentary by Gordon Groh, MD on the Andrade-Silva et al. article.
Marc Swiontkowski, MD
Each month during the coming year, OrthoBuzz will bring you a current commentary on a “classic” article from The Journal of Bone & Joint Surgery. These articles have been selected by the Editor-in-Chief and Deputy Editors of The Journal because of their long-standing significance to the orthopaedic community and the many citations they receive in the literature. Our OrthoBuzz commentators will highlight the impact that these JBJS articles have had on the practice of orthopaedics. Please feel free to join the conversation about these classics by clicking on the “Leave a Comment” button in the box to the left.
The common knowledge applied in managing open fractures (asepsis, irrigation and debridement, immobilization, and wound protection against infection) was obtained from the surgical experience accrued during World War I. Despite the overall improvement in outcomes from applying that knowledge, the varying severity of associated soft-tissue injuries created considerable ambiguity regarding optimal treatments during the years that followed.
”Prevention of Infection in the Treatment of 1,025 Open Fractures of Long Bones” by Ramon Gustilo and John Anderson in the June 1976 edition of JBJS classified open fractures into three types of increasing severity based on wound size, level of contamination, and osseous/soft-tissue injury. In general, more severe open fractures have a worse clinical prognosis for infection, nonunion, and other complications, although actual outcomes vary depending on numerous additional clinical factors. Also, high-energy Type III open fractures are not homogeneous, and in response to that variation, in 1984 Gustilo et al. further classified Type III open fractures into A, B, and C subtypes according to the severity of soft-tissue injury, the need for vascular reconstruction, and worsening prognosis.
However, the reliability of the Gustilo classification has been questioned in recent years. Clinical researchers have observed that the assessment of surface injuries does not always reflect deeper damage and does not account for tissue viability and tissue necrosis, which tends to develop with time after high-energy injuries. Also, a 1993 study found only moderate interobserver agreement among users of the classification. The limitless variety of injury patterns, mechanisms, and severities is almost impossible to be contained in a limited number of discrete categories.
As the management of open fractures continues to evolve, the 1976 Gustilo and Anderson treatment recommendation against primary internal fracture fixation for most Type III injuries due to high infection rates no longer represents the standard of care. Stabilization, even with internal fixation, for many of these fractures promotes healing, allows early rehabilitation, restores function, and reduces the risk of infection and malunion.
While “best practices” may have changed, the Gustilo-Anderson classification still correlates well with the risk of infection in patients with comorbid medical illnesses and other complications. It remains an easy-to-use classification system that has formed the foundation for open fracture management during the last four decades, with good but imperfect prognostic and therapeutic implications. It remains widely accepted for research and training purposes, and it provides the preferred basic language for communicating about open fractures.
Konstantinos Malizos, MD, PhD
JBJS Deputy Editor
The statistics about osteoporosis and associated fragility fractures are sobering:
- One-quarter of adults living in the US currently have osteoporosis or low bone density.
- Twenty-four percent of people aged 50 and older who sustain a hip fracture will die within a year after the fracture.
- Patients who have had one fragility fracture have an 86% increased risk for a second fracture.
Amid these troubling data stands hope from an effective, team-based clinical response—the fracture liaison service (FLS). In the April 15, 2015 edition of JBJS, Miller et al . explain how an FLS works and the results it achieves.
The authors define the fracture liaison service as “a coordinated care model of multiple providers who help guide the patient through osteoporosis management after a fragility fracture to help prevent future fractures.” The three key players on the FLS team are a coordinator (usually an advanced-practice provider), a physician champion (whom the authors say should be an orthopaedic surgeon), and a “nurse navigator.” Miller et al. describe the roles these FLS core team members play (including patient care and education and communication with other clinical services and administrators), suggest ways to organizationally justify an FLS, and lay out a stepwise implementation roadmap.
The authors conclude that an FLS “is adaptable to any type of health-care system, improves patient outcomes, and decreases complications and readmissions related to secondary fractures.” And there’s an important fringe benefit: “The FLS can help improve performance on quality measures…and help health-care organizations during this transition from volume payment to quality payment,” they say.